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Radiotherapy

Apr 8, 2025, 11:04

Understanding Salvage Radiotherapy: How It Works, Benefits, and Drawbacks

Salvage radiotherapy is a key treatment option for men experiencing a recurrence of prostate cancer after initial therapy, such as surgery. Unlike primary radiation therapy, which targets the cancer during its first appearance, salvage radiotherapy is used when the cancer returns—often detected through rising PSA levels. This approach aims to eliminate remaining cancer cells and prevent further spread. In this brief overview, we’ll explore how salvage radiotherapy works, why it’s important, and weigh its potential benefits and limitations.

What Is Salvage Radiotherapy?

Salvage radiotherapy (SRT) is a second-line cancer treatment used primarily for patients who experience a recurrence of cancer—such as biochemical relapse of prostate cancer—after undergoing initial curative treatment like radical prostatectomy (surgical removal of the prostate) or, in some cases, prior radiation therapy.

Its main goal is to target and eliminate residual cancer cells that were not detected or completely removed during the initial treatment. This is particularly important in cases where prostate-specific antigen (PSA) levels begin to rise again after surgery—a sign of biochemical recurrence (BCR)—even if no cancer is visibly detected on imaging.

SRT is considered a second-line or “salvage” therapy because it is applied after the primary treatment has failed to fully control the cancer. It is not part of the initial treatment plan but becomes necessary when there’s evidence that the cancer might be returning.

What Are the Main Types of Salvage Radiotherapy?

Salvage radiotherapy (SRT) for recurrent prostate cancer can be classified into several types based on timing, dosage and field size, combination with other treatments, and treatment modalities. Tailoring these factors helps optimize outcomes and reduce side effects for patients experiencing biochemical recurrence after prostatectomy.

Timing-Based Classification

I referenced the study you shared, where early salvage radiotherapy (initiated at PSA 0.2–0.5 ng/mL) was the most significant predictor of improved outcomes, specifically bRFS and MFS (hazard ratios HR = 0.52 and HR = 0.58, respectively).

Dosage and Field Size

Your earlier text mentioned high-dose salvage RT (e.g., 70.2 Gy), and that most series use lower doses compared to primary RT, helping keep toxicity lower.

Combination with Other Therapies

The study noted that 32.6% of patients received neoadjuvant or concurrent androgen deprivation therapy (ADT).

Treatment Modalities

While your texts didn’t go into depth on external beam radiation therapy (EBRT) versus other modalities, the mention of prostate bed-only radiotherapy and hypofractionated RT helped guide this part.

When Should Salvage Radiotherapy Be Initiated?

The evidence from the provided texts strongly suggests that SRT should be initiated when the PSA level is low, ideally below 1.0 μg/L and even better when it is 0.5 μg/L or less. While PSADT is an important prognostic factor, the PSA level at the time of initiation appears to be a key determinant of outcome. Guidelines, such as those from the European Association of Urology, recommend considering SRT at PSA levels up to 1.5 μg/L. The overall consensus from the provided texts points towards earlier intervention at lower PSA levels for potentially better outcomes.

In a 2007 publication in The Journal of Urology, Howard M. Sandler and Mario A. Eisenberger noted that a rising PSA (0.2-0.4 ng/ml) after radical prostatectomy indicates recurrence. While restaging is advised, metastases are often not detectable at low PSA. Local therapy is most effective for slow PSA increases (<1.0 ng/ml) and lower Gleason scores, suggesting localized recurrence. Approximately 70% of patients with biochemical relapse are unlikely to die from the disease but remain at risk for metastasis and morbidity. Currently, there’s no consensus on standard systemic treatment, making clinical trial participation a priority.

Side Effects of Salvage Radiotherapy: What to Expect?

While salvage radiotherapy (SRT) is a crucial treatment for controlling recurrent prostate cancer after surgery, it’s important for patients to understand that they may experience certain side effects. These side effects can vary depending on individual factors such as the dose of radiation, the area being treated, and the patient’s overall health.

Genitourinary (GU) Side Effects

Genitourinary (GU) Side Effects (Related to the Urinary System): Urine issues are common and can include blood in your urine (hematuria), pain or burning sensation when passing urine (dysuria), increased frequency of urination (needing to go more often), increased urgency to urinate (feeling a sudden need to go), less control of urine (urinary incontinence), and scar tissue in your urethra (urethral stricture), which can cause difficulty passing urine. Studies have reported that some patients may experience longer-term urinary issues, with grade 2 or higher late GU toxicity occurring in around 11% of patients at 5 years . This can include issues like stenosis (narrowing) of the urethra or bladder neck.

Braide et al. reported in the 2020 Scandinavian Journal of Urology that at a median 10-year follow-up after surgery, patients receiving SRT had a 1.2 to 1.4 times higher relative risk of urinary symptoms compared to those who had only radical prostatectomy. The study concluded that SRT generally results in acceptable long-term side effects, although a subset of men may develop severe issues.

Gastrointestinal (GI) Side Effects

Gastrointestinal (GI) Side Effects (Related to the Bowel): Bowel issues can include loose stools (diarrhea), blood in your stool (rectal bleeding), and proctitis, which is inflammation of the rectum potentially causing discomfort. These side effects are often mild to moderate. Longer-term bowel issues (grade 2 or higher) have been reported in a smaller percentage of patients, around 4.7% in one study.

Sexual Side Effects

Based on the texts provided, the main sexual side effect mentioned in relation to salvage radiotherapy (SRT) is problems with erections, also known as erectile dysfunction. One of the texts also mentions that a quality of life study found that the group of patients treated with SRT reported worse outcomes in sexual function compared to those who did not have a recurrence after radical prostatectomy, suggesting a broader impact on sexual health beyond just erectile function. However, the texts do not offer extensive details on the specifics of these sexual side effects, which can vary among individuals depending on factors like pre-treatment function, radiation extent, individual health, and the use of hormone therapy.

Zwahlen et al. reported in the 2024 Clinical and Translational Radiation Oncology journal that 57.3% of patients had mild to moderate erectile dysfunction (ED) after radical prostatectomy, while 42.7% had severe ED. Five years after salvage radiotherapy (sRT), 29.4% reported mild to moderate ED. Dose intensification of sRT (70Gy vs 64Gy) showed no significant impact on erectile function recovery or new ED.

Radiotherapy for Prostate

Read OncoDaily’s Special Article About Prostate Radiotherapy

Reducing the Risk of Long-Term Side Effects

To minimize the potential for long-term side effects following salvage radiotherapy (SRT), a multi-faceted approach is recommended. Regular follow-up appointments with your radiation oncologist and urologist are essential for ongoing monitoring, allowing for the early detection and management of any late-occurring side effects affecting urinary, bowel, or sexual function. Strict adherence to the post-treatment care plan provided by your healthcare team is crucial; this may involve taking prescribed medications, performing pelvic floor exercises to improve urinary control, or using other recommended therapies. Adopting a healthy lifestyle plays a significant role in recovery and overall well-being; this includes maintaining a balanced diet rich in nutrients, engaging in regular physical activity as advised by your doctor, and avoiding smoking and excessive alcohol consumption. Open and timely communication with your healthcare team is paramount – promptly reporting any new or worsening symptoms, no matter how minor they may seem, ensures that you receive appropriate and timely medical attention. By actively engaging in these strategies, you can work towards minimizing the impact of long-term side effects and improving your overall quality of life after SRT.

Comparison: Salvage Radiotherapy vs. Adjuvant Radiotherapy

The key difference between adjuvant and salvage radiotherapy lies in their timing relative to the initial surgery. Adjuvant radiotherapy is given as a preventative measure shortly after radical prostatectomy, even if the PSA level is undetectable. It’s typically recommended for patients who had high-risk features identified during surgery, such as cancer that has grown outside the prostate (pT3/pT4) or positive surgical margins. The primary goal of adjuvant radiotherapy is to eradicate any remaining microscopic cancer cells in the surgical area and thereby prevent a future recurrence.

In contrast, salvage radiotherapy (SRT) is administered later, only when there is evidence of biochemical recurrence, which is detected by a rising PSA level after it had initially dropped to an undetectable level following surgery. Patient selection for SRT is primarily based on this rising PSA, and the treatment is most effective when started at lower PSA levels. The goal of SRT is to control this localized recurrence in the prostate bed and prevent it from spreading to other parts of the body.

Innovations in Salvage Radiotherapy

Salvage radiotherapy can significantly impact patient survival, primarily by improving progression-free survival, especially when initiated at low PSA levels. The addition of ADT to SRT has been shown to improve overall survival. Factors like the PSA level at treatment start, Gleason grade, and PSADT are crucial in predicting the outcome of SRT. While SRT offers a chance for long-term disease control, it’s essential to consider individual patient characteristics and overall life expectancy when determining its potential benefit.

How Much Does Salvage Radiotherapy Cost?

The cost of salvage radiotherapy is not specified in the provided texts, and it can vary significantly based on several factors. These include the duration of the treatment course, which is often five days a week for four to eight weeks. The specific equipment and techniques used, such as advanced methods like Intensity-Modulated Radiation Therapy (IMRT) or Image-Guided Radiation Therapy (IGRT), can also influence the cost, with more specialized treatments like proton therapy generally being more expensive. The charges of the healthcare facility, whether it’s a hospital or an outpatient center, and the geographic location can also lead to variations in cost.

Luo et al. reported in the 2016 International Journal of Radiation Oncology Biology Physics that over 10 years, the total cost of adjuvant radiation therapy (ART) was estimated at $24,548, while early salvage radiation therapy (ESRT) cost $16,755. With ART showing a 13% increase in PSA success (PSA <0.1 ng/mL), the incremental cost-effectiveness ratio (ICER) of ART versus ESRT was $59,949 per additional PSA success.

Recovery of the Body After Salvage Radiotherapy

Recovery after salvage radiotherapy is a gradual process where listening to your body is key, avoiding strenuous activity initially and gradually increasing it. Managing potential side effects like bowel and urinary issues through diet, hydration, and prescribed medications is important, and sexual health concerns should be discussed with your doctor. Promptly report any severe pain, significant bleeding, fever, inability to urinate, or persistent digestive issues to your healthcare team. Regular follow-up appointments, including PSA testing and physical exams, are crucial for monitoring your recovery and detecting any recurrence or late side effects. Open communication with your medical team about any concerns is essential for optimal post-treatment care.

Written by Aren Karapetyan, MD

FAQ

What is Salvage Radiotherapy (SRT)?

SRT is radiation therapy given after prostate surgery (radical prostatectomy) when the prostate-specific antigen (PSA) level rises again, indicating the cancer has recurred.

When should SRT be started?

Ideally, SRT should be started when the PSA level is low, preferably under 1.0 μg/L and even better below 0.5 μg/L.

What are the common side effects of SRT?

Common side effects include bowel issues (loose stools, blood in stool), urine issues (blood in urine, pain, frequency, incontinence), and sexual issues (erection problems).

What are the benefits of SRT?

SRT aims to control local recurrence, prevent or delay the spread of cancer, and can improve progression-free and overall survival, especially when started early

How does SRT differ from adjuvant radiotherapy?

Adjuvant RT is given shortly after surgery to high-risk patients to prevent recurrence, while SRT is given later if PSA rises.

Does SRT improve survival rates?

Yes, studies show SRT can improve progression-free survival, and combining it with hormone therapy can improve overall survival.

How much does SRT cost?

The cost varies depending on treatment duration, techniques used, facility charges, and insurance coverage. It's best to check with your healthcare provider and insurance.

What is the recovery like after SRT?

Recovery involves managing potential side effects, gradually returning to activities, and attending regular follow-up appointments for PSA monitoring.

How can long-term side effects of SRT be minimized?

Regular follow-ups, adherence to care plans, healthy lifestyle choices, and prompt reporting of symptoms can help minimize long-term side effects.

How effective is SRT?

The effectiveness of SRT is best when started at low PSA levels, with 5-year biochemical progression-free survival rates varying from 35% to 85% depending on PSA at initiation.